Target Obesity Early to Succeed in Kids

Action Points

Two different studies look at the effectiveness of behavioral and multidisciplinary interventions for weight management in young children.

In one study, obese children ages 3 to 5 years randomized to an intensive, multidisciplinary intervention had significantly more success in reducing their body mass index (BMI) than those in a "usual care" arm.

In a second study, age under 10 at treatment initiation was predictive of beneficial effect of therapy in terms of decline in BMI.

Overweight children are more successful in losing weight and maintaining the loss when anti-obesity interventions begin early -- as young as age 3, two European studies suggested.

In one study, 44% of those ages 6 to 9 years who were moderately obese at baseline experienced a clinically meaningful 0.5-unit decrease in body mass index (BMI) z-score with behavioral treatment, compared with only 8% of those ages 14 to 16, according to Pernilla Danielsson, RN, PhD, of the Karolinska Institute in Stockholm, and colleagues.

And in a randomized trial comparing a multidisciplinary intervention and usual care for children ages 3 to 5 years, the intervention led to multiple significant benefits in body weight and composition, including a mean decrease in BMI z-score of −0.5 units, and the changes persisted for a year, reported Gianni Bocca, MD, and colleagues from the University of Groningen in the Netherlands.

Both studies were published online in the Archives of Pediatrics and Adolescent Medicine, accompanied by an editorial by Jennifer A. Woo Baidal, MD, and Elsie M. Taveras, MD, of Harvard Medical School in Boston.

"More and more evidence points to early childhood as a pivotal time for preventing in young children an obesity trajectory that is hard to alter by the time they enter middle school," observed Baidal and Taveras.

The Swedish study enrolled 643 obese children ages 6 to 16, following them for 3 years. Moderate obesity was defined as a BMI z-score of 1.6 to 3.5, and severe obesity was a score above 3.5.

A total of 54 of the moderately obese children were ages 6 to 9, 194 were 10 to 13, and 124 were 14 to 16.

Among those who were severely obese, 91 were in the youngest group, 98 in the middle group, and 82 were in the older group.

Among the severely obese children in the youngest group, 58% had a reduction of at least 0.5 units in BMI z-scores at 3 years, while the severely obese adolescents had no change whatsoever at year 1, 2, or 3.

Further analyses revealed that severely obese boys in the middle age group had a BMI z-score decrease of −0.5 (95% CI −0.64 to −0.36) compared with a change of only −0.1 (95% CI −0.35 to 0.11, P<0.001) for girls.

Maternal obesity also influenced the outcome. For children who were severely obese but whose mothers' weight was normal, the decrease in z score was −0.6 (95% CI −0.79 to −0.37), while the change was −0.3 (95% CI −0.46 to −0.24, P=0.04) for those whose mothers also were obese.

Finally, the researchers determined that for each year earlier the treatment was begun there was a 47% greater likelihood of achieving a change of −0.5 units at year 3.

"The results show that the degree of obesity was an important predictor of treatment outcome and that treatment outcome varied by age," stated Danielsson and colleagues.

In the Dutch study, Bocca and colleagues enrolled 75 children ages 3 to 5 who were overweight or obese, randomizing them to a 16-week comprehensive program of daily physical activity, dietary instruction, and psychological counseling for parents.

The usual-care group was provided with advice on diet and activity.

At baseline, mean BMI z-score was 2.7.

At week 16, the mean difference in BMI z-scores between the groups was 0.2 units (95% CI 0.02 to 0.42, P=0.03).

In the usual-care group, significant differences were seen at 16 weeks only for BMI, BMI z-score, and hip circumference z-score.

A year after the treatment was begun, greater differences from baseline in the multidisciplinary group were seen for BMI (P=0.03), waist circumference, (P=0.02), BMI z-score (P=0.02), and waist circumference z-score (P=0.01).

There also was a trend for a significant difference in visceral fat (P=0.08), the researchers found.

"An important result of our study is the positive effect on the reduction of abdominal fat mass in the intervention group, shown by decreases in [waist circumference]-z and [visceral fat]," Bocca and colleagues observed.

The importance of the change in abdominal fat lies in the fact that adipocytes in visceral fat produce adipokines, which promote oxidative stress, inflammation, insulin resistance, and ultimately diabetes and the metabolic syndrome.

Additional follow-up will be needed to determine the longer term effects of the early multidisciplinary intervention, the researchers noted.

In their editorial, Baidal and Taveras wrote, "The early childhood years are periods of sensitivity to environmental influences, maximum societal care and protection, multiple settings for intervention, and changeability."

They recommended these strategies for all children younger than 5:

Replacement of sugar-sweetened beverages with water and unhealthy snacks with fruit and vegetables

Decreased television and screen time to minimize exposure to food advertising

Encouraging physical activity for at least an hour each day

Promotion of adequate, good quality sleep

The editorialists also suggested that "Seeking solutions from 'positive deviants,' i.e., families who have succeeded where many others have not to change their health behaviors, maintain their child's body mass index, and develop resilience in the context of sometimes adverse environments, could provide strategies for interventions that can be generalized and promoted to improve the outcomes of other children."

The Swedish study was funded by the Swedish Association of Local Authorities and Regions, the National Board of Health and Welfare, the Stockholm Free Masons' Foundation for Chidren's Welfare, and the Karolinska Institute.

The Dutch study was sponsored by Hutchinson Whampoa Limited in Hong Kong.

All authors and editorialists reported no financial disclosures.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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